Comparative effectiveness of pediatric HIV disclosure interventions in Uganda

描述（由申请人提供）：截至2009年底，估计有210万15岁以下儿童感染艾滋病毒，其中近90%居住在撒哈拉以南非洲（SSA）。随着抗逆转录病毒疗法（ART）的普及和护理的改善，越来越多的围产期感染儿童存活到青春期。据估计，乌干达有150 000名感染艾滋病毒的儿童。虽然针对儿童的艾滋病毒护理和治疗计划正在扩大，但卫生服务提供者和护理人员面临的日益严峻的挑战是向受感染的儿童披露艾滋病毒血清状况。在撒哈拉以南非洲进行的研究表明，只有2%至37.8%的15岁以下艾滋病毒感染儿童知道自己的艾滋病毒状况。在乌干达，尽管针对儿童的艾滋病毒服务迅速扩大，但很少有医疗服务提供者接受过如何支持向受感染儿童披露艾滋病毒诊断结果的正式培训。随着针对儿童的艾滋病毒护理和治疗计划的扩大，以满足撒哈拉以南非洲不断增长的艾滋病毒感染儿童的需求，迫切需要有效，具有成本效益，文化上适当和可扩展的披露干预措施，以提高护理人员与他们的孩子沟通慢性疾病和艾滋病毒的能力，并促进持续的积极心理健康，行为和临床结果的艾滋病毒感染儿童谁知道他们的艾滋病毒状况。我们提出了一个为期4年的项目，以测试的有效性，我们设计的认知行为干预，以支持发展适当的披露艾滋病毒感染的儿童，他们的照顾者。干预是由社会认知理论和信息-动机-行为模型，并将适应艾滋病毒感染儿童的照顾者，由我们的团队成员与美国总统艾滋病紧急救援计划（PEPFAR）的资金支持开发的多方面计划的组成部分。我们的具体目标是：目标1：在乌干达，为了确定认知行为干预对增加照顾者向7-12岁的艾滋病毒感染儿童披露儿童艾滋病毒诊断的有效性。我们将评估干预措施，采用阶梯楔形准实验，在四个坎帕拉地区艾滋病毒诊所实施，共有400个双胞胎，并随访24个月。我们假设，加强干预将导致增加披露率。我们将比较参与干预措施的护理人员-儿童二元组和参与乌干达国家艾滋病毒护理和治疗指南指导的标准护理的二元组之间的信息披露。目标2：确定披露对直接和长期照顾者和儿童心理健康，儿童行为和临床结果的影响，以及干预是否改变了这些影响。我们假设，干预将减轻披露的潜在不利影响，包括抑郁，焦虑和行为问题。目的3：评估干预的增量成本和成本效益。这项研究的结果将为乌干达和其他国家关于儿科艾滋病毒护理和治疗的国家政策提供信息。

DESCRIPTION (provided by applicant): At the end of 2009, there were an estimated 2.1 million children under the age of 15 years living with HIV, with almost 90% residing in sub-Saharan Africa (SSA). With increased availability of antiretroviral therapy (ART) and improved care, increasing numbers of perinatally infected children are surviving into adolescence. There are an estimated 150,000 HIV-infected children in Uganda. While HIV care and treatment programs for children are expanding, a growing challenge facing health providers and caregivers is disclosure of HIV serostatus to infected children. Studies conducted in SSA have indicated that only 2% to 37.8% of HIV-infected children < 15 years know their HIV status. In Uganda, despite the rapid expansion of HIV services for children, very few health providers receive formal training in how to support disclosure of an HIV diagnosis to an infected child. As HIV care and treatment programs for children are scaled up to meet the demand of a growing population of HIV-infected children in SSA, there is an urgent need for effective, cost-effective, culturally appropriate, and scalable disclosure interventions that improve caregivers ability to communicate with their child about chronic illness and HIV, and promote sustained positive mental health, behavioral and clinical outcomes of HIV-infected children who learn their HIV status. We propose a 4-year project to test the effectiveness of a cognitive-behavioral intervention that we have designed to support developmentally appropriate disclosure to HIV-infected children by their caregiver. The intervention is informed by social cognitive theory and the information-motivation-behavior model, and would adapt components of a multi- faceted program for caregivers of HIV-infected children, developed by members of our team with funding support from the US President's Emergency Plan for AIDS Relief (PEPFAR). Our specific aims are: AIM 1: To determine the effectiveness of a cognitive-behavior intervention for increasing disclosure of children's HIV diagnosis by caregivers to their HIV-infected children age 7-12 years old in Uganda. We will evaluate the intervention using a stepped wedge quasi-experiment implemented at four Kampala area HIV clinics, with a total of 400 caregiver-child dyads, and followed for 24 months. We hypothesize that the enhanced intervention will lead to increased disclosure rates. We will compare disclosure among caregiver- child dyads enrolled in the intervention and dyads enrolled in standard care guided by Uganda National guidelines for HIV Care and Treatment. AIM 2: To determine the effect of disclosure on immediate and longer- term caregiver and child mental health, and child behavioral and clinical outcomes, and whether the intervention modifies these effects. We hypothesize that the intervention will attenuate potential adverse effects of disclosure, including depression, anxiety, and behavioral problems. AIM 3: To assess the incremental cost, and cost-effectiveness of the intervention. The findings of this study will inform Ugandan and other countries national policies on pediatric HIV care and treatment.